+61 422 153 727
Are you the patient?
If ‘No’, please provide your name and relationship to the patient
Your Phone Number
Name of Patient’s Health Fund
Dr Timothy WrightDr David LoganDr Paul PepperDr Sean FerenczDr Nicole OrganDr Nicole OrganDr Tony AzziDr Andrew BruntonDr Ed BatemanDr Lyndal Harborneother
If ‘other’ please specify
Hunter Valley PrivateLake Macquarie PrivateCharlestown PrivateNewcastle PrivateGosford PrivateLingard PrivateWarners Bay PrivateNewcastle Endoscopy CentreOther
Name of Operation/Procedure
Date of Operation/Procedure
Have you had any problems with anaesthetics in the past?
If ‘Other’ please specify
Do you have any Allergies?(this includes all tablets, puffers, patches, sprays, injections, eye drops, etc.)
Do you take any regular medications?(Including ALL prescription, ‘over the counter’, vitamins and herbal preparations)
Do you take any blood thinners? (including fish oil, krill oil or any derivatives or similar preparations)
Do you smoke?
If ‘Other’ please specify
Do you drink alcohol?
If ‘Yes’ please specify how many standard drinks per day
Have you used any ‘recreational’ drugs or have in the last few weeks?Have you used any ‘recreational’ drugs or have in the last few weeks?
(This information is confidential and only required as some drugs can have serious interactions and consequences when having an anaesthetic)
YesNorather not say
Do you have, or have you ever had, any of the following?
Any trouble with your heart or cardiovascular system? (this could include high blood pressure, chest pains, angina, heart attacks, coronary artery stents, coronary artery bypass surgery, heart rhythm problems, having a pacemaker or defibrillator, strokes or mini strokes)
Any trouble with your lungs or respiratory system? (this could include asthma, obstructive sleep apnoea (OSA) with or without CPAP mask use, or smoking-
Gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia?
Thyroid or any other endocrine disease?
Any neurological diseases/disorders (including stroke, epilepsy, tumours, MS, muscular disorders/dystrophy, fainting episodes, migraine, paralysis)
Any Mental Health Issues (including depression, anxiety, bipolar disorder, schizophrenia)
Blood clots or excessive bleeding/bleeding disorders? (eg. deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia, and others)
With regards to your teeth or dentition – what do you have? (please select all that apply)
Loose tooth or teethChipped tooth or teethCaps, crowns, or veneersImplant(s)Bridge(s)BracesTemporary crowns, etcPartial upper denturesPartial lower denturesFull upper denturesFull lower denturesYour own teeth +/- fillings only +/- retainer wire (from braces)
Upload medical information (please feel free to upload any medical reports, test results, Specialist letters or supporting information)
Name and telephone numbers of your doctors (GPs and Specialists)
Do you give your consent for me to contact your other doctors if required? (to provide you with the safest anaesthetic your anaesthetist may need to contact your other doctors to obtain test results, specialist letters, or other information. This allows better understanding of your health, meaning your anaesthetic can be individualised appropriately)
Your anaesthetist will receive all the information submitted via this questionnaire. Depending upon your answers, your anaesthetist may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, your anaesthetist may be satisfied with the information submitted and be ready to proceed with your anaesthetic as is.
By submitting this form you confirm the information provided is true and correct to the best of your knowledge and can be relied upon by your anaesthetist in making clinical decisions.
Is there anything else you would like to mention?
If ‘Other’, please specify
Send me a copy of this message (email only)
If the confirmation email does not appear in your Inbox please check your Junk/Spam folder
PO Box 437, New Lambton, NSW 2305
© 2017 Logo & Website Design By Logoinn All Rights Reserved.